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Published on: June 21, 2019
Levetiracetam Prophylaxis for Children Admitted With Traumatic Brain Injury
Taryn-Leigh Surtees1, Ishani Kumar2, Hugh J L Garton3
1Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
Insights
Levetiracetam is the preferred antiseizure medication (ASM) for pediatric traumatic brain injury (TBI), but its prophylactic use is inconsistent. Further research is needed to optimize ASM prophylaxis and prevent early posttraumatic seizures (EPTSs).
Area of Science:
- Pediatric Neurology
- Neurocritical Care
- Traumatology
Background:
- Prophylactic antiseizure medications (ASMs) for pediatric traumatic brain injury (TBI) are understudied.
- Levetiracetam is the preferred ASM despite a lack of strong evidence.
- Prophylaxis prescription is inconsistent.
Purpose of the Study:
- To evaluate clinical and radiographic features informing ASM prescription for pediatric TBI.
- To assess the utilization patterns of prophylactic ASMs in children with TBI.
- To investigate the incidence of early posttraumatic seizures (EPTSs) in children receiving ASM prophylaxis.
Main Methods:
- Retrospective study of children admitted with TBI (2017-2019).
- TBI severity assessed using Glasgow Coma Scale (GCS).
- Neuroradiologists reviewed head CT and MRI; Fisher exact tests and regression analyses were conducted.
Main Results:
- 44% of 167 children received ASM prophylaxis, exclusively levetiracetam.
- Prophylaxis more common in younger children, those with neurosurgical intervention, abnormal imaging (intraparenchymal hematoma), or GCS ≤12.
- Six children (13.6%) on ASM developed EPTSs; 23.5% with GCS ≤12 on levetiracetam developed EPTSs.
Conclusions:
- Levetiracetam is exclusively used for EPTS prophylaxis, despite potential inferiority to phenytoin.
- Intraparenchymal hematoma >1 cm was associated with ASM prophylaxis, irrespective of GCS.
- Significant variability in prophylaxis prescription warrants further study on ASM efficacy and EPTS prevention.
Background:
Prophylactic antiseizure medications (ASMs) for pediatric traumatic brain injury (TBI) are understudied. We evaluated clinical and radiographic features that inform prescription of ASMs for pediatric TBI. We hypothesized that despite a lack of evidence, levetiracetam is the preferred prophylactic ASM but that prophylaxis is inconsistently prescribed.
Methods:
This retrospective study assessed children admitted with TBI from January 1, 2017, to December 31, 2019. TBI severity was defined using Glasgow Coma Scale (GCS) scores. Two independent neuroradiologists reviewed initial head computed tomography and brain magnetic resonance imaging. Fisher exact tests and descriptive and regression analyses were conducted.
Results:
Among 167 children with TBI, 44 (26%) received ASM prophylaxis. All 44 (100%) received levetiracetam. Prophylaxis was more commonly prescribed for younger children, those with neurosurgical intervention, and abnormal neuroimaging (particularly intraparenchymal hematoma) (odds ratio = 10.3, confidence interval 1.8 to 58.9), or GCS ≤12. Six children (13.6%), all on ASM, developed early posttraumatic seizures (EPTSs). Of children with GCS ≤12, four of 17 (23.5%) on levetiracetam prophylaxis developed EPTSs, higher than the reported rate for phenytoin.
Conclusions:
Although some studies suggest it may be inferior to phenytoin, levetiracetam was exclusively used for EPTS prophylaxis. Intraparenchymal hematoma >1 cm was the single neuroimaging feature associated with ASM prophylaxis regardless of the GCS score. Yet these trends are not equivalent to optimal evidence-based management. We still observed important variability in neuroimaging characteristics and TBI severity for children on prophylaxis. Thus, further study of ASM prophylaxis and prevention of pediatric EPTSs is warranted.
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